cochrane database of systematic reviews (reviews) || whole-body vibration training for patients with...

Whole-body vibration training for patients with

neurodegenerative disease (Review)

Sitjà Rabert M, Rigau Comas D, Fort Vanmeerhaeghe A, Santoyo Medina C, Roqué i Figuls

M, Romero-Rodríguez D, Bonfill Cosp X

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2012, Issue 2

http://www.thecochranelibrary.com

Whole-body vibration training for patients with neurodegenerative disease (Review)

Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .

5BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

5METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

14ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .

17DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

20REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

24CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 Whole-body vibration vs an active physical therapy (short-term effects) in Parkinson’s disease,

Outcome 1 Body balance (Functional Reach). . . . . . . . . . . . . . . . . . . . . . . . 39

Analysis 1.2. Comparison 1 Whole-body vibration vs an active physical therapy (short-term effects) in Parkinson’s disease,

Outcome 2 Gait (Timed Up and Go test). . . . . . . . . . . . . . . . . . . . . . . . . 40

Analysis 2.1. Comparison 2 Whole-body vibration vs an active physical therapy (long-term effects) in Parkinson’s disease,

Outcome 1 UPDRS III motor score. . . . . . . . . . . . . . . . . . . . . . . . . . . 41


Outcome 2 Body balance (Berg Balance Scale and Tinetti test). . . . . . . . . . . . . . . . . . 41


Outcome 3 Gait (TUG test and Stand-walk-sit test). . . . . . . . . . . . . . . . . . . . . 42

42APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

43HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

43CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

44DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

44INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

iWhole-body vibration training for patients with neurodegenerative disease (Review)


[Intervention Review]

Whole-body vibration training for patients withneurodegenerative disease

Mercè Sitjà Rabert1, David Rigau Comas2 , Azahara Fort Vanmeerhaeghe3, Carme Santoyo Medina4 , Marta Roqué i Figuls5 , Daniel

Romero-Rodríguez6 , Xavier Bonfill Cosp7

1Physiotherapy Department, Blanquerna School of Health Science, Universitat Ramon Llull, Barcelona, Spain. 2Iberoamerican

Cochrane Centre. Institute of Biomedical Research (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Spain,

Barcelona, Spain. 3EUSES Sports Science, Universitat de Girona, Girona, Spain. 4Physiotherapy Department, Blanquerna School of

Health Science, Universitat Ramon Llull /Barcelona Day Hospital of the MS Foundation. CEMCat, Barcelona, Spain. 5Iberoamerican

Cochrane Centre. Institute of Biomedical Research (IIB Sant Pau), Barcelona, CIBER Epidemiología y Salud Pública (CIBERESP),

Spain, Barcelona, Spain. 6EUSES Sports Science, Universitat de Girona, Girona, Spain. 7Iberoamerican Cochrane Centre - Institute of

Biomedical Research (IIB Sant Pau), CIBER Epidemiología y Salud Pública (CIBERESP), Spain - Universitat Autònoma de Barcelona,

Barcelona, Spain

Contact address: Mercè Sitjà Rabert, Physiotherapy Department, Blanquerna School of Health Science, Universitat Ramon Llull,

C/Padilla, 226-232, Barcelona, Barcelona, 08026, Spain. [email protected].

Editorial group: Cochrane Movement Disorders Group.

Publication status and date: New, published in Issue 2, 2012.

Review content assessed as up-to-date: 6 May 2011.

Citation: Sitjà Rabert M, Rigau Comas D, Fort Vanmeerhaeghe A, Santoyo Medina C, Roqué i Figuls M, Romero-Rodríguez D,

Bonfill Cosp X. Whole-body vibration training for patients with neurodegenerative disease. Cochrane Database of Systematic Reviews2012, Issue 2. Art. No.: CD009097. DOI: 10.1002/14651858.CD009097.pub2.


A B S T R A C T

Background

Whole-body vibration (WBV) may be a complementary training to standard physical rehabilitation programmes and appears to have

potential benefits in the sensorimotor system performance of patients with neurodegenerative diseases.

Objectives

The aim of this review was to examine the efficacy of WBV to improve functional performance according to basic activities of daily

living (ADL) in neurodegenerative diseases. Additionally, we wanted to assess the possible effect on signs and symptoms of the disease,

body balance, gait, muscle performance, quality of life and adverse events.

Search methods

We searched the following electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library,2011 Issue 4), MEDLINE (1964 to 6 May 2011; via PubMed), EMBASE (1980 to 6 May 2011; via Ovid), PeDro (1929 to May

2011; via website), CINAHL (to September 2011; via Ovid) and PsycINFO (1806 to 6 May 2011; via Ovid).

Selection criteria

We included randomised controlled trials comparing single or multiple sessions of WBV to a passive intervention, any other active

physical therapy or WBV with different vibration parameters.

1Whole-body vibration training for patients with neurodegenerative disease (Review)


mailto:[email protected]

Data collection and analysis

Two review authors independently selected trials for inclusion, assessed trial quality and extracted data. Disagreement was resolved by

discussion or, if necessary, referred to a third review author.

Main results

We included 10 trials, of which six focused on Parkinson’s disease and four on multiple sclerosis. None of the studies reported data

on the primary outcome (functional performance). In Parkinson’s disease, after pooling two studies, a single session of WBV caused a

significant improvement of gait measured using the Timed Up and Go test (TUG) in comparison to standing exercises (mean difference

-3.09, 95% confidence interval -5.60 to -0.59; P = 0.02; I2 = 0%). Nevertheless, longer duration of WBV did not show significant

results in comparison with physical therapy in body balance or signs and symptoms measured with the Unified Parkinson’s Disease

Rating Scale (UPDRS). In multiple sclerosis there was no evidence of a short-term or long-term effect of WBV on body balance, gait,

muscle performance or quality of life.

Adverse events were reported in few trials. In those trials that reported them, the intervention appeared to be safe.

Authors’ conclusions

There is insufficient evidence of the effect of WBV training on functional performance of neurodegenerative disease patients. Also,

there is insufficient evidence regarding its beneficial effects on signs and symptoms of the disease, body balance, gait, muscle strength

and quality of life compared to other active physical therapy or passive interventions in Parkinson’s disease or multiple sclerosis. More

studies assessing other functional tests and accurately assessing safety are needed before a definitive recommendation is established.

P L A I N L A N G U A G E S U M M A R Y

Whole-body vibration platform training in patients with neurodegenerative diseases

Rehabilitation is considered to be a key symptomatic and supportive treatment for neurodegenerative diseases. Exercise training using

vibratory platform (whole body vibration) has been recently introduced as a complementary treatment to rehabilitation.This review

identified ten trials performing whole body vibration (WBV) in neurodegenerative diseases: six in Parkinson’s disease and four in multiple

sclerosis. Diversity in treatments and outcomes measures makes difficult to quantitatively compare the effect of WBV intervention

across studies and to assess its efficacy. There is insufficient evidence to determine the potential benefits of WBV training in functional

performance according to activities of daily life, body balance, signs and symptoms of disease, muscle performance, and quality of life

in patients with neurodegenerative diseases. Adverse events were poorly reported in the included studies, but this kind of training seems

to be a safe intervention. These conclusions are based on a small number of studies with a limited methodological quality.



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Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.

Verylowquality:Weareveryuncertainabouttheestimate.



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B A C K G R O U N D

Neurodegenerative diseases represent a challenge from both a so-

cial and health care point of view. The clinical manifestations of

this group of illnesses tend to be similar; they have an insidi-

ous beginning and become progressive, chronic and debilitating.

The prevalence of neurodegenerative diseases varies broadly de-

pending on the type of disease and geographical area (Ferri 2005;

WHO/WFN 2004). Alzheimer’s and Parkinson’s disease are the

most frequent neurodegenerative diseases and are estimated to af-

fect up to 18 million and 6 million of people worldwide respec-

tively (Schapira 1999; WHO/WFN 2004). Alzheimer’s disease is

characterised by a severe cortical atrophy and the triad of senile

plaques, neurofibrillary tangles and neuropil threads. The motor

and cognitive impairment characteristic of Parkinson’s disease is

caused by the loss of melanin-containing neurons and the presence

of Lewy bodies in the substantia nigra and other pigmented nuclei

of the brainstem. Since their incidence is age-related a substantial

increase of this disease in developing countries such as India and

China is expected in the coming years (WHO/WFN 2004).

Amyotrophic lateral sclerosis (ALS) and multiple sclerosis are also

considered neurodegenerative diseases. ALS is less frequent but is

characterised by a selective degeneration of the upper and lower

motor neurons that cause progressive weakness leading to paraly-

sis and death within three to six years after the onset of the dis-

ease. Multiple sclerosis is an autoimmune disorder characterised

by destruction of myelin in the central nervous system (CNS)

and also axonal atrophy in the chronic progressive forms. It is the

commonest non traumatic neurological disorder affecting young

adults (Adams 1997). Although patient profile, physiopathology

and some clinical features and therapeutic options differ broadly

between neurodegenerative diseases, their common threats are a

remarkable decline in functional capacity, the associated loss of

independence and impairment of quality of life.

Physical rehabilitation is considered to be a key symptomatic and

supportive treatment for neurodegenerative diseases, but the evi-

dence to support its use is relatively poor (Khan 2008; Mehrholz

2010). The effect of vibration stimuli on the nervous and muscular

system has been studied in different fields (Goetz 2009;Cardinale

2003) and has evolved into full body training known as Whole

Body Vibration (WBV). Exercise training using vibratory plat-

forms may be a complementary training to standard physical reha-

bilitation programmes. WBV provides a mechanical oscillation of

a specific frequency and amplitude of displacement (Jordan 2005;

Luo 2005; Cardinale 2006; Rehn 2007). It generates an oscilla-

tory vertical motion (vertical platform) or a movement around a

horizontal axis (oscillating platform) (Marín 2010). The contact

surface of the platform transmits a vibration (in feet or hands)

throughout the body. This vibration produces rapid changes in

the length of the muscle and activates the myotatic reflex. The

stretching of muscles is detected by the proprioceptors (mainly the

neuromuscular spindles) thus activating the called tonic vibration

reflex (Eklund 1966; Cardinale 2006).

The wWhole body vibration training haves been studied in others

populations. Current evidence suggests that exercise programmes

(involving static or dynamic exercises, or both) on vibratory plat-

forms have beneficial effects in older populations (Merriman 2009;

Mikhael 2010; Totosy de Zepetnek 2009). It has been shown

that vibration interventions with a low amplitude (ranging from

0.7 to 14 mm), a moderate frequency (ranging from 10 to 50

Hz) and short periods of exposure are safe and have beneficial ef-

fects on muscular strength (Bosco 1998; Cardinale 2006; Jordan

2005; Luo 2005), bone mineral density (Mikhael 2010; Totosy

de Zepetnek 2009) and body balance in both young healthy and

elderly populations (Merriman 2009). In addition WBV may have

short-term effects, obtained immediately after a single session of

vibration stimuli and long-term effects, obtained after regular vi-

bration stimuli (multiple sessions) (Rehn 2007).

In recent years, some rehabilitation programmes have introduced

vibratory platform training in neurodegenerative diseases such

as Parkinson’s disease or multiple sclerosis (Schuhfried 2005;

Turbanski 2005). The aim of this review is to clarify the poten-

tial benefits of whole-body vibration training in the treatment of

neurodegenerative diseases

O B J E C T I V E S

To examine the efficacy of WBV training for improving function-

ality and balance, decreasing symptoms and improving quality of

life in neurodegenerative diseases.

M E T H O D S

Criteria for considering studies for this review

Types of studies

We included randomised clinical trials (RCT) or quasi-ran-

domised clinical trials.

Types of participants

We considered studies that included participants with any type of

neurodegenerative diseases, such as Parkinson’s disease, multiple

sclerosis, amyotrophic lateral sclerosis (ALS), Alzheimer’s disease,

Huntington’s chorea, etc. We grouped the effects of the interven-

tions separately by illness.



Types of interventions

This review focused on any intervention with WBV which evalu-

ated both short-term (single session) and long-term effects (mul-

tiple sessions). We included trials where WBV was compared to:

• a passive intervention (waiting list, non-treatment, usual

lifestyle);

• any other active physical therapy intervention (balance

programme, walking, resistance training etc.);

• another WBV intervention under different vibration

parameters.

Types of outcome measures

Primary outcomes

• Functional performance according to basic activities of

daily living(ADL)

Secondary outcomes

• Signs and symptoms of the disease

• Body balance: includes all the assessments (test, scale etc.)

that analyse equilibrium, postural control or proprioception in a

standing position

• Gait: includes all the measurements (test, scale etc.) that

analyse the action of walking

• Muscle performance

• Quality of life

• Adverse events

Search methods for identification of studies

Electronic searches

We searched the following electronic databases: the Cochrane

Central Register of Controlled Trials (CENTRAL) (The CochraneLibrary, 2011 Issue 4), MEDLINE (1964 to 6 May 2011; via

PubMed), EMBASE (1980 to 6 May 2011; via Ovid), PeDro

(1929 to May 2011; via website), CINAHL (to September 2010;

via Ovid) and PsycINFO (1806 to 6 May 2011; via Ovid). We

applied no language restrictions.

We designed the following search strategy for MEDLINE

(PubMed) and we modified this strategy to search the other

databases (Appendix 1):

1 whole body vibration[tw] OR vibration exercise[tw] OR

wbv[tw]

2 randomized controlled trial[pt] OR controlled clinical trial[pt]

OR randomized[tiab] OR placebo[tiab] OR drug therapy[sh] OR

randomly[tiab] OR trial[tiab] OR groups[tiab]

3 1 AND 2

Searching other resources

We handsearched conference proceedings from the World Physical

Therapy Congress (World Confederation for Physical Therapy;

http://www.wcpt.org/), Congreso Nacional de Neurología (SociedadEspañola de Neurología; http://www.sen.es/), International Con-

ference of the European Committee for Treatment and Research in

Multiple Sclerosis (ECTRIMS; http://www.ectrims.eu/), World

Parkinson Congress (http://www.worldpdcongress.org/) and In-

ternational Conference on Alzheimer’s and Parkinson’s diseases

(http://www2.kenes.com/adpd/Pages/Home.aspx). We reviewed

conference proceedings from January 2002 to March 2011.

Additionally, we checked the reference lists from relevant studies

to identify further eligible studies. We also identified ongoing and

unpublished trials by contacting researchers in the field.

Data collection and analysis

Selection of studies

Two review authors independently screened the title, abstract and

descriptors of references identified by the searches for possible in-

clusion and they obtained the full text of studies if required. We

agreed the list of studies eligible for inclusion and in case of dis-

agreements we called in a third review author to reach consensus.

Data extraction and management

We independently extracted data using a data extraction form

which was designed and tested prior to use. Disagreement was

resolved by discussion or, if necessary, referred to a third review

author.

Assessment of risk of bias in included studies

Two review authors independently evaluated each study’s risk of

bias according to the criteria outlined in the Cochrane Handbookfor Systematic Reviews of Interventions (Higgins 2008). We evalu-

ated the following domains: random sequence generation (selec-

tion bias); allocation concealment (selection bias); blinding (per-

formance bias and detection bias); selective reporting (reporting

bias); the description of the number and the causes of follow-up

loss and other bias. We evaluated each criterion and assigned a

judgement of low, unclear or high risk of bias, based on the infor-

mation reported in each study. Review authors were not blinded to

author and source institution of included studies. Disagreements

were resolved by involving a third author. If necessary, we con-

tacted study authors to obtain additional data for enhanced ’Risk

of bias’ assessment.



http://www.wcpt.org/



http://www.sen.es/

http://www.sen.es/

http://www.sen.es/

http://www.ectrims.eu/



http://www.worldpdcongress.org/



http://www2.kenes.com/adpd/Pages/Home.aspx






Measures of treatment effect

We measured treatment effect with mean differences for contin-

uous outcomes when assessed with the same scale. We computed

standardised mean differences when outcomes were measured with

different scales (i.e. body balance measured with the Tinetti test

and Berg Balance Scale).

Although we had planned to present absolute measures in relation

to baseline risks observed in the included studies, this was ulti-

mately not done due to poor reporting of data in studies.

Unit of analysis issues

For all included cross-over trials, we assessed the appropriateness

of their analysis methods from their publications. Since all of them

were adequately analysed using design-adjusted tests, we reported

their statistical results, P values and conclusions in the results sec-

tion with no modifications. Cross-over trials could not be pooled

due to clinical heterogeneity in comparisons and outcomes.

Dealing with missing data

The studies included had low numbers of patients lost to follow-

up. We analysed data as presented in the original trials, without

assumptions regarding missing data.

Assessment of heterogeneity

We assessed clinical heterogeneity based on comparability of in-

terventions and outcome measures. We only attempted pooling

of data for clinically homogeneous trials. When appropriate, we

assessed statistical heterogeneity using the I2 statistic to determine

heterogeneity observed across studies. I2 values superior to 50%

indicated the existence of substantial heterogeneity.

We organised the analyses and presentation of results according to

the two subgroup analyses that had been planned in the protocol:

1. Type of neurodegenerative disease (Alzheimer’s disease,

Parkinson’s disease, multiple sclerosis, ALS, others).

2. WBV training duration. We assessed the short-term effects

of WBV training, defined as the effects immediately observed

after application of a single WBV session and the long-term

effects of WBV training, defined as a performance after regular

WBV sessions (Rehn 2007).

Data synthesis

Whenever pooling of data was possible (i.e. the included trials as-

sessing a common comparison provided adequate data for a spe-

cific outcome), we carried out a meta-analysis using the generic

inverse variance method by means of a fixed-effect model. When

pooling was not possible, we carried out a qualitative description

and assessment of the results and conclusions of the included stud-

ies. We performed all statistical analyses with the Cochrane Review

Manager (RevMan 5) statistical package (RevMan 2008), follow-

ing the recommendations of the Cochrane Handbook for SystematicReviews of Interventions (Higgins 2008).

R E S U L T S

Description of studies

See: Characteristics of included studies; Characteristics of excluded

studies.

See: Characteristics of included studies; Characteristics of excluded

studies.

Results of the search

We retrieved he following results from the searches:

Source Hits retrieved

MEDLINE 305

EMBASE 264

PeDro 27

CENTRAL (the Cochrane Central Register of Controlled Trials) 176

CINAHL 64

PsycINFO 52



(Continued)

World Physical Therapy Congress (World Confederation for

Physical Therapy)

13

Congreso Nacional de Neurología (Sociedad Española de Neu-

rología)

0

International Conference of the European Committee for Treat-

ment and Research in Multiple Sclerosis (ECTRIMS)


0

World Parkinson Congress 1

International Conference on Alzheimer’s and Parkinson’s disease 1

The search strategies identified a total of 903 references. Removal

of duplicates resulted in 573 references. We obtained 49 full-text

studies for consideration and eventually excluded 39 of them.

Included studies

We included 10 studies with 264 participants. The effects of

WBV were assessed in two different neurodegenerative diseases:

Parkinson’s disease (six trials) and multiple sclerosis (four trials).

Seven trials used a parallel design (Arias 2009; Broekmans 2010;

Chouza 2011; Ebersbach 2008; Haas 2006 (a); Schuhfried 2005;

Turbanski 2005) and three used a cross-over design (Haas 2006

(b); Jackson 2008; Schyns 2009). Six trials studied the short-term

effects of WBV in a single session (Chouza 2011; Haas 2006 (a);

Haas 2006 (b); Jackson 2008; Schuhfried 2005; Turbanski 2005)

and three trials studied the long-term effects of WBV (up to 20

weeks training programme) (Broekmans 2010; Ebersbach 2008;

Schyns 2009). One trial presented short-term and long-term re-

sults for WBV, after a single session and after a five-week training

programme (Arias 2009).

Participants

Six studies were conducted in patients with Parkinson’s disease

(Arias 2009; Chouza 2011; Ebersbach 2008; Haas 2006 (a); Haas

2006 (b); Turbanski 2005). The mean age of participants in these

trials was 67.9 years and 31.5% of them were female. Four stud-

ies were conducted in patients with multiple sclerosis (Broekmans

2010; Jackson 2008; Schuhfried 2005; Schyns 2009). The mean

age of participants in these trials was 48.9 years and 73.3% of

them were female. No studies were conducted in others neurode-

generative diseases.

Interventions

Different vibration platform types were used in the included tri-

als. Four studies used a rotational platform (oscillating platform)

that rotates in a sinusoidal manner around an anteroposterior

axis that thrusts the right and left legs upward alternately (Arias

2009; Chouza 2011; Ebersbach 2008; Jackson 2008). Two studies

used a platform that generates vertical sinusoidal displacements

(Broekmans 2010; Schyns 2009). Finally, four studies used a plat-

form that performs a non harmonious generation of oscillating

movements (random) in vertical and horizontal planes (transversal

axis) (Haas 2006 (a); Haas 2006 (b); Schuhfried 2005; Turbanski

2005).

Vibration parameters in the rotational platform were diverse: vi-

bratory frequency ranged from 2 to 26 Hz; amplitude ranged from

6 to 14 mm and vibration time per session ranged from 30 seconds

to 5 minutes. The platform that generated vertical displacements

used higher vibratory frequencies (ranging from 20 to 50 Hz) with

an amplitude of 2.5 mm and a vibration time per session that

ranged from 2.5 to 16.5 minutes. The platforms that generated

a random vertical and horizontal movement used more homoge-

neous vibration parameters: vibratory frequency up to 6 Hz; am-

plitude of 3 mm and vibration time per session of 5 minutes.

Comparison

There were four trials that compared the effects of WBV to a pas-

sive intervention, mostly a resting period (Broekmans 2010; Haas

2006 (a); Haas 2006 (b); Schuhfried 2005). In four trials WBV was

compared to active physical therapy interventions that included

standard balance training, moderate walking, conventional resis-

tance training or standing exercises (Arias 2009; Ebersbach 2008;

Schyns 2009; Turbanski 2005). One trial compared two modali-



ties of WBV with different frequencies of vibration (Jackson 2008)

and finally one trial compared different frequencies of vibration

and standing exercises (Chouza 2011).

Excluded studies

We excluded 39 trials after reading their full text. Reasons for

exclusion are detailed in the Characteristics of excluded studies.

The most frequent reason of exclusion was that the participants

included were not patients with a neurodegenerative disease. All

identified studies that included older persons were obtained in full

text to ascertain if they provided data on any subgroup with a

neurodegenerative disease.

Risk of bias in included studies

The assessments of methodological quality for the individual

studies are detailed in the ’Risk of bias’ tables included in the

Characteristics of included studies and summarised in Figure 1

and Figure 2.

Figure 1.



Figure 2.



Overall, the methodological quality of the studies was low. None

of the included studies reported an adequate method for randomi-

sation sequence generation or concealed the intervention alloca-

tion.

Allocation

Three studies did not use an adequate method of allocation con-

cealment (Arias 2009; Ebersbach 2008; Schyns 2009). The rest of

the studies did not provide any information, so were of unclear

risk of bias.

Blinding

One study blinded the intervention to the investigator but not to

the patient (Schuhfried 2005). Six studies were open (Broekmans

2010; Ebersbach 2008; Haas 2006 (a); Haas 2006 (b); Jackson

2008; Schyns 2009) and three studies did not provide information

about the blinded status of participants.

We paid special attention if the studies included a blind assessor

because the characteristics of the intervention hamper any strategy

to blind the intervention assignment to the investigators or par-

ticipants. Overall, seven studies used a blinded assessor to evaluate

all or some outcomes (Arias 2009; Chouza 2011; Ebersbach 2008;

Haas 2006 (b); Jackson 2008; Schuhfried 2005; Schyns 2009). In

two studies the outcome assessors were aware of the intervention

assignment (Broekmans 2010; Haas 2006 (a)) and one study did

not provide enough information.

Selective reporting

In nine studies (Arias 2009; Broekmans 2010; Chouza 2011;

Ebersbach 2008; Jackson 2008; Haas 2006 (b); Schuhfried 2005;

Schyns 2009; Turbanski 2005) the authors reported data on all

outcomes. Nonetheless, in one study (Haas 2006 (a)) the authors

reported data from only one of two pre-specified outcomes.

Other potential sources of bias

Seven studies were free of other potential sources of bias (Arias

2009; Broekmans 2010; Chouza 2011; Ebersbach 2008; Jackson

2008; Schuhfried 2005; Turbanski 2005). Two studies (Haas 2006

(a); Haas 2006 (b)) were affected by other sources of bias. In one of

them (Haas 2006 (a)) the number of participants in each group was

highly unbalanced (19 patients in the intervention group and nine

patients in the control group). The second one (Haas 2006 (b))

used a cross-over design but without a wash-out period between

intervention phases suggesting a carry-over effect. It is not clear if

one study (Schyns 2009) was also affected by a carry-over effect

because it had a two-week wash-out period between the four-week

intervention phases.

Effects of interventions

See: Summary of findings for the main comparison Whole-

body vibration compared to an active physical therapy (short-term

effects) for neurodegenerative disease; Summary of findings 2

Whole-body vibration compared to an active physical therapy

(long-term effects) for neurodegenerative disease

None of the studies reported results for the primary outcome

(functional performance according to basic activities of daily living

(ADL)). We present the results for secondary outcomes grouped

by type of neurodegenerative disease, by short-term or long-term

effects of whole-body vibration (WBV) and finally by comparison

group. Not all of the studies provided data on all secondary out-

comes. Pooling of data was only attempted when clinical homo-

geneity was observed, regarding participants, active and control

interventions and effect measures.

1. Results for Parkinson’s disease

We analysed a total of six studies including 236 participants with

Parkinson’s disease (Arias 2009; Chouza 2011; Ebersbach 2008;

Haas 2006 (a); Haas 2006 (b); Turbanski 2005).

1.1. Short-term effects of WBV

Five trials including 215 participants (Arias 2009; Chouza 2011;

Haas 2006 (a); Haas 2006 (b); Turbanski 2005) studied the effects

of a single session of WBV.

1.1.1. WBV compared to a passive intervention

Two studies compared the WBV with a passive intervention con-

sisting of a resting period (Haas 2006 (a); Haas 2006 (b)).

Haas 2006 (a) included 26 participants and assessed propriocep-

tive performance as a measure of body balance using a tracking

task based on knee extension and flexion movements. No signif-

icant differences were detected either between pre and post-tests

or between experimental and control groups (only reported in

graphics). Bradykinesia (a symptom of Parkinson’s disease) was not

properly detailed in the results of the publication.

Haas 2006 (b) included 68 participants and used a cross-over de-

sign. The study assessed signs and symptoms of the disease us-

ing the Unified Parkinson’s Disease Rating Scale (UPDRS) mo-

tor score at baseline and after both interventions (WBV or rest-

ing period). There was no wash-out period. The UPDRS motor

score was significantly reduced (P < 0.01, two-way repeated mea-

sures ANOVA test) after WBV treatment, whereas no significant

changes in UPDRS motor score were detected after the control

period.

None of the studies reported data on adverse effects.



1.1.2. WBV compared to an active physical therapy

intervention

Three studies compared WBV to an active physical therapy in-

tervention. One study compared WBV with moderate walking

(Turbanski 2005). Another study compared WBV with standing

exercises (same set of exercises performed without vibration) (Arias

2009) and assessed both short-term and long-term effects. Finally,

the third study compared different frequencies of vibration and

standing exercises (same set of exercises performed without vibra-

tion) (Chouza 2011).

Two studies comparing WBV with standing exercises including a

total of 45 participants assessed body balance with the Functional

Reach test. The pooled mean difference for body balance was 19.83

(95% confidence interval (CI) -20.99 to 60.65;P = 0.34; Analysis

1.1; Figure 3 ) without evidence of statistical heterogeneity ( I2 =

0%). No differences were observed between WBV group in com-

parison to standing exercise. Both studies had the same vibration

parameters (frequency at 6 Hz and amplitude at 13 mm) and a

similar protocol intervention.

Figure 3. Forest plot of comparison: 1 Whole-body vibration vs an active physical therapy (short-term

effects) in Parkinson’s disease, outcome: 1.1 Body balance (Functional Reach).

The third study, not included in the pooled analysis, reported

the results of body balance using a different assessment measure

(postural stability on a moving and unstable platform) (Turbanski

2005). This study included 52 participants assessed in two stan-

dardised conditions (narrow and tandem standing) on their ability

to maintain postural stability on a moving and unstable platform.

Postural stability was improved after WBV treatment in both posi-

tions but only significantly in the tandem standing (P = 0.01, from

a two-way ANOVA test). Analyses of group differences resulted in

a significantly higher postural control improvement in the WBV

group (P = 0.04, one-way ANOVA with Bonferroni correction).

The two studies comparing WBV with standing exercises (45 par-

ticipants) assessed gait with the Timed Up and Go (TUG) test

(Arias 2009; Chouza 2011). The pooled mean difference for body

gait was -3.09 (95% CI -5.60 to -0.59;P = 0.02; Analysis 1.2;

Figure 4) with evidence of statistical heterogeneity ( I2 = 0%). Gait

was improved significantly in the WBV group in comparison to

standing exercises.

Figure 4. Forest plot of comparison: 1 Whole-body vibration vs an active physical therapy (short-term

effects) in Parkinson’s disease, outcome: 1.2 Gait (Timed Up and Go test).


1.2. Long-term effects of WBV

Two studies including 42 participants studied the effects of a long-

term WBV intervention (Arias 2009; Ebersbach 2008), both com-

pared to an active physical therapy intervention.



1.2.1. WBV intervention compared to an active physical

therapy intervention

Arias 2009 included 21 participants and compared WBV with

standing exercises (same set of exercises performed without vi-

bration). Ebersbach 2008 included 21 participants and compared

WBV with standard balance exercises performed on a tilt board.

These two studies assessed body balance and gait using different

tests. We pooled results for these outcomes using a standardised

mean difference (SMD).

No differences were found in the meta-analysis between WBV

compared to active physical therapy in signs/symptoms of the dis-

ease, body balance and gait. The two studies assessed signs and

symptoms of the diseases by UPDRS III test (motor score) (Arias

2009; Ebersbach 2008). The pooled mean difference for UPDRS

motor score was -0.81 (95% CI -4.68 to 3.07;P = 0.68; Analysis

2.1; Figure 5) without evidence of statistical heterogeneity (I2=

22%) at the end of the study.(No differences were observed be-

tween the two studies in body balance using the Berg Balance Scale

(Arias 2009) and the Tinetti test (Ebersbach 2008), presenting a

SMD of 0.36 (95% CI -0.26 to 0.97;P = 0.25; Analysis 2.2; Figure

6) without evidence of statistical heterogeneity (I2 = 0%).

Figure 5. Forest plot of comparison: 2 Whole-body vibration vs an active physical therapy (long-term

effects) in Parkinson’s disease, outcome: 2.1 UPDRS III motor score.


effects) in Parkinson’s disease, outcome: 2.2 Body balance (Berg Balance Scale and Tinetti test).

No differences were observed between the two studies in gait as-

sessed by the TUG test (Arias 2009) and the stand-walk-sit test

(Ebersbach 2008). The SMD was -0.41 (95% CI -1.02 to 0.21;P

= 0.19;; Analysis 2.3; Figure 7) without evidence of statistical het-

erogeneity (I2 = 0%).


effects) in Parkinson’s disease, outcome: 2.3 Gait (TUG test and Stand-walk-sit test).



In addition, Arias 2009 assessed quality of life using the PDQ-

39 test (Parkinson’s disease questionnaire) in the 21 participants

and there were no differences between groups (P = 0.143, two-

way ANOVA test).


2. Results for multiple sclerosis

We analysed a total of four studies including 62 participants with

multiple sclerosis (Broekmans 2010; Jackson 2008; Schuhfried

2005; Schyns 2009).

2.1. Short-term effects of WBV

Two trials including 27 participants studied the effects of a sin-

gle session of WBV (Jackson 2008; Schuhfried 2005). One study

compared WBV with an active physical intervention consisting of

standing exercises (in a squat position: slight flexion at the hips,

knee and ankle joint) while applying a burst-transcutaneous elec-

trical nerve stimulation (TENS) on the non dominant forearm

(Schuhfried 2005). The second study compared two WBV modal-

ities with different vibration parameters (Jackson 2008). No trials

comparing WBV with passive interventions were identified.

2.1.1. WBV compared to an active physical therapy

intervention

Schuhfried 2005 was conducted as a pilot study comparing WBV

to standing exercises. A total of 12 participants assessed body bal-

ance with the Sensory Organization Test (SOT) and the Func-

tional Reach test (FR). Gait was assessed using the TUG test. Val-

ues of change from baseline of these tests were not significantly

different between groups (P = 0.18, Mann-Whitney U-test). All

patients completed the study without any adverse effects except

one patient who experienced increased fatigue (no details on which

they group belonged to).

2.1.2. WBV compared to WBV with different vibration

parameters

Jackson 2008 conducted a cross-over study including 15 partici-

pants. Muscle performance was assessed with the maximal isomet-

ric torque (of knee extensors and flexors) using an isokinetic dy-

namometer (Biodex Medical Systems®). There were no significant

differences in isometric torque between the 2 Hz and 26 Hz WBV

conditions (P value not presented for repeated measures analysis

of variance). There were no adverse effects during the study.

2.2. Long-term effects of WBV

Two trials including 35 participants studied the effects of a long-

term WBV intervention (Broekmans 2010; Schyns 2009) com-

pared with either passive intervention (usual lifestyle) (Broekmans

2010) or with an active physical therapy intervention (same set of

exercises performed without vibration) (Schyns 2009).

2.2.1. WBV compared to a passive intervention

Broekmans 2010 analysed 25 participants during 20 weeks. The

assessment of body balance was done with the Berg Balance test

and gait was assessed by the TUG test, the two-minute walk test

and the 25-foot walk test. Finally, the muscle performance of knee

extension was assessed through isokinetic dynamometer (Biodex

Medical Systems®). No differences between groups were detected

for any of the variables (maximal isometric knee-extensor and

knee-flexor torque in both knee angles: group × time effect, knee-

extensors: 45°, P = 0.07; 90°, P = 0.23; knee-flexors: 45°, P = 0.64;

90°, P = 0.57); Berg Balance scale, P = 0.15; TUG test, P = 0.26;

two-minute walk test, P = 0.25; 25-foot walk test, P = 0.64; all

P values from a repeated measures ANOVA). Adverse events were

not properly detailed in the publication.

2.2.2. WBV compared to any other active physical therapy

intervention

Schyns 2009 included 10 participants in a cross-over study. The

authors provided the results by intervention group for the assess-

ment of gait (measured with the TUG test and the 10-metre walk

tests), muscle performance (maximal isometric force using a hand-

held dynamometer) and quality of life (assessed by the Multiple

Sclerosis Impact Scale (MSIS-29)). No statistically significant dif-

ferences were found for any of these outcomes (TUG test, P = 0.72;

10-metre walk test, P = 0.56; muscle force: quadriceps (right) P =

0.846, hamstrings (right) P = 1.00; MSIS-29: Physical P = 0.760

and Psychological P = 0.634; all P values from Wilcoxon signed

rank test). The results of assessing signs and symptoms of the dis-

ease with the Multiple Sclerosis Spasticity Scale MSSS-88 and the

Modified Ashworth Scale were not provided. Adverse events were

not properly detailed in the publication.



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Lowquality:Furtherresearchisverylikelytohaveanimportantimpactonourconfidenceintheestimateofeffectandislikelytochangetheestimate.

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D I S C U S S I O N

Summary of main results

The aim of this review was to examine the efficacy of whole-body

vibration (WBV) to improve functional performance according to

basic activities of daily living (ADL)in neurodegenerative diseases.

We included 10 studies, only focusing on Parkinson’s disease (six

trials) and multiple sclerosis (four trials), and assessing either a

single training session (short-term effects) or multiple sessions over

a period of time (long-term effects). None of the studies reported

data on the primary outcome (functional performance) and it

was only possible to analyse partial evidence regarding secondary

outcomes.

Overall, methodological quality of the studies included in this

review was low and inconsistent. Heterogeneity of interven-

tions,outcome measures and units of measurement used in the in-

cluded studies makes difficult to compare WBV parameters among

studies and assess its efficacy. For these reasons, the evidence about

its efficacy is weak and no strong conclusions can be derived.

Signs and symptoms

Signs and symptoms were analysed using different scales. For

Parkinson’s disease studies, bradykinesia was analysed either as a

movement velocity of the knee or using the Unified Parkinson’s

Disease Rating Scale (UPDRS) (specifically the UPDRS motor

score) for a general assessment of signs and symptoms. For multi-

ple sclerosis studies, the Multiple Sclerosis Spasticity Scale (MSSS-

88) or the Modified Ashworth Scale was used.

Only two studies focusing on Parkinson’s disease performed WBV

in several training sessions compared to active physical therapy

(same exercise programme without vibration or standard balance

training). Comparative data from both studies related to signs and

symptoms (UPDRS test) (Arias 2009; Ebersbach 2008) were anal-

ysed and no differences were found. Bradykinesia was measured

in only one trial, but this parameter was not properly detailed in

the results (Haas 2006 (b)).

Body balance

Most of the analysed studies have focused on functional mobil-

ity as the main outcome measure (most of the included trials as-

sessed balance skill). Balance and gait impairment compromise the

ability to perform ADL independently, and these limitations also

lead to secondary complications such as falls and social isolation (

Zijltra 2010). Body balance is an outcome analysed with different

tests such as the Functional Reach test, the Berg Balance Scale,

the Tinetti test, posturography (Sensory Organization Test), the

Nottingham Sensory Assessment and the Pull test score from the

UPDRS score.

Regarding balance in Parkinson’s disease and multiple sclerosis,

both with single or multiple sessions, the analysis not showed a

statistically significant differences between groups.

Gait

Gait was an outcome evaluated using different tests in the studies

in this review, such as the Timed Up and Go (TUG) test, the

stand-walk-sit test, the two-minute walk test, the 25-foot-walk

test and the 10-metre-walk test, and even using a gait recording

system analysing gait (m/s), cadence (steps/s), step amplitude (m)

and turn time (s).

Our analysis shows an improvement for walking capacity in

Parkinson’s disease after one session of WBV training compared

to active physical therapy (measured by TUG) with a wide con-

fidence interval (from futility to clinical relevance). On the other

hand, after multiple sessions of WBV a non significant trend to

improvement in Parkinson’s disease was registered and no differ-

ences among groups were found in multiple sclerosis. Despite this,

it is necessary to be careful when drawing conclusions, since these

results are based on few studies.

Muscle performance

Although muscle weakness is one of the most common symptoms

of neurodegenerative diseases, it has been poorly reported in the

studies included in our review. The maximal isometric torque was

either recorded by an isokinetic dynamometer (Biodex Medical

System) or a hand-held dynamometer (using a ’make test’) only

for multiple sclerosis, while this outcome was not assessed for

Parkinson’s disease.

Three of the four studies focusing on multiple sclerosis reported

this outcome (Broekmans 2010; Jackson 2008; Schyns 2009) and

two of them analysed the effect of multiple sessions of WBV

(Broekmans 2010; Schyns 2009). The first one compared five

weeks of WBV to an active physical therapy training programme

(Schyns 2009). The second one compared 20 weeks of WBV to

a passive intervention and analysed muscle performance using a

protocol where volume and intensity were increased systematically

according to the overload principle (Broekmans 2010). None of

the studies showed a significant improvement in muscle capacity.

Muscle weakness contributes to gait disturbances and postural in-

stability and compromises the ability to perform ADL indepen-

dently (Falvo 2008). Extended research is required to analyse this

outcome on a long-term basis, in order to provide conclusions that

are currently not feasible.

Quality of life

The individual perception of physical, mental and social effects of

illness on daily living is one of the most important determinants



http://archie.cochrane.org/sections/documents/#REF-Zijltra-2010

http://archie.cochrane.org/sections/documents/#REF-Zijltra-2010

http://archie.cochrane.org/sections/documents/#STD-Broekmans-2010


http://archie.cochrane.org/sections/documents/#STD-Jackson-2008

http://archie.cochrane.org/sections/documents/#STD-Jackson-2008

http://archie.cochrane.org/sections/documents/#STD-Schyns-2009










of overall quality of life (García 2000). In spite of this, quality

of life was only evaluated in two trials. In the Parkinson’s disease

study, the Parkinson’s disease questionnaire (PDQ) test was used

(Arias 2009) and in the multiple sclerosis study, the MSIS-29 test

(Schyns 2009) was employed. No studies showed a significant im-

provement after a WBV intervention compared to active physical

therapy intervention.

Adverse events

Five studies using a single session did not report adverse events

(Arias 2009; Chouza 2011; Haas 2006 (a); Haas 2006 (b);

Turbanski 2005) and two studies showed no side effects associated

with the WBV intervention (Jackson 2008; Schuhfried 2005).

Jackson 2008 reported the case of a participant complaining from

muscle fatigue.

Regarding the studies looking for long-term effects of WBV, two of

them did not report adverse effects (Arias 2009; Ebersbach 2008),

while the other two considered WBV to be safe but did not report

this information in a proper way (Broekmans 2010; Schyns 2009).

Overall completeness and applicability ofevidence

Participants

Participants’ disability ranged from mild to moderate. In these

cases, the main goal of the rehabilitation process was to maintain

or improve functional capacity according to ADL. WBV seems to

be a safe and applicable intervention for people with disabilities,

facilitating balance, strength and body posture tasks.

Intervention

People suffering neurodegenerative diseases have physical limita-

tions to the development of independent ADL, both at home

and in community environments (Compston 2002). To improve

these conditions, conventional physiotherapy modalities involve

strength, balance and aerobic exercises, drawing up strategies to

improve daily tasks such as gait or other functional actions, and

quality of life (Keus 2007; Motl 2005; Rimmer 2010). Although

physical exercise is an important element in rehabilitation and

seems to be well tolerated in neurodegenerative disease patients,

the evidence is poor because it is based on a limited number of stud-

ies with low methodological quality (Asano 2009; Dalgas 2008;

Falvo 2008; Keus 2007; Rimmer 2010).

Physical exercise programmes applied in neurodegenerative dis-

ease patients are usually over 10 weeks (Dalgas 2008). Most of the

studies included in this review had short training periods (three

to five weeks) (Arias 2009; Ebersbach 2008; Schyns 2009), with

the exception of one trial with a 20-week training programme

(Broekmans 2010). Most of the studies included in this review are

consistent with the currently recommended number of training

sessions per week for neurodegenerative diseases (two to three ses-

sions/week) (Dalgas 2008; Falvo 2008). This is an important issue

to consider since fatigue is a symptom of functional limitation in

neurodegenerative diseases (Compston 2002), especially in people

who have lower functional capacity (Garber CE 2003; Friedman

1993; Friedman 2001). In these patients, fatigue induced by the

rehabilitation programme can even lead to increased inactivity and

facilitate major physical deconditioning (Rimmer 2005). Some

studies applying WBV in older people (Merriman 2009) showed

that vibration therapy requires a shorter time per session com-

pared to conventional interventions to achieve similar effects on

balance and strength. This can be explained by the enhanced mus-

cle activation associated with WBV (Abercromby 2007).Thus vi-

bration platforms allow for important stimuli of proprioceptors

when performing exercises in easy positions. This way a training

programme can be performed with lower levels of muscle fatigue,

achieving better adaptation of functional mobility compared to

conventional therapy and with a low risk of negative effects in the

workout process.

This review considers all kinds of vibration fluctuations, i.e. ver-

tical, rotational and transversal axis. In a review of WBV, Marín

2010 points out the greater long-term effects of vertical vibration

platforms compared to rotational platforms, although the latter

have good effects in the short-term. Taking into account the im-

portant variability of the interventions and assessments carried out

in the analysed studies, our review has not considered a subgroup

evaluation by different platforms.

Outcomes

None of the analysed studies assessed functional performance with

global scales. All the studies focused on more specific outcomes

such as gait, balance, muscle strength and quality of life. Such great

variability in testing procedures leads to a complex analysis of the

obtained outcomes, which compromises their external validity.

Quality of the evidence

Overall methodological quality of the studies was deficient. In the

first place, although all studies considered the use of a random

sequence generation, only four declared the method used, which

greatly increased the risk of bias.

Secondly, there was a lack of data on allocation concealment in

most studies. Only three of them reported information about this

item.

In physiotherapy studies it is difficult to blind investigators or par-

ticipants and it is not possible to avoid performance bias. With the



http://archie.cochrane.org/sections/documents/#REF-Compston-2002

http://archie.cochrane.org/sections/documents/#REF-Compston-2002

http://archie.cochrane.org/sections/documents/#REF-Garber-CE-2003



http://archie.cochrane.org/sections/documents/#REF-Friedman-1993




aim of reducing some methodological limitations, seven studies

used a blinded assessor to evaluate all or some outcomes. Eight

studies were free of other biases but it should be noted that most

studies had a small sample size. Additionally, there was hetero-

geneity between trials in terms of design (study duration, different

tests or scales used) and characteristics of interventions (protocol

training, exercises used), and these differences make it difficult to

obtain a clinically significant outcome.

Finally, only five studies reported information about withdrawals,

dropouts or losses to follow-up. Several studies did not describe

adverse events of interest for this review.

Agreements and disagreements with otherstudies or reviews

There are three recent systematic reviews of WBV in neurodegen-

erative diseases, two focused on the effects of WBV in the Parkin-

son’s disease population and one in a special population (including

Parkinson’s disease and multiple sclerosis patients but also in el-

derly, post-menopausal women and patients with stroke or spastic

diplegia).

The most recent review shows the effects of WBV (including a

chair providing vibration to the body) on sensorimotor perfor-

mance in people with Parkinson’s disease (Lau 2011). This review

summarised the results of the trials in a narrative format with no

pooled analysis and considered similar outcomes to our review.

Although this review did not find any significant differences be-

tween multiple sessions of WBV and conventional exercise, the

authors report a trend towards improved body balance with WBV.

Another short review (Pinto 2010) summarised the results of the

studies on WBV in patients with Parkinson’s disease but they did

not include authors’ conclusions. Finally, a review of WBV in a

mixed population (Madou 2008) also considered the effects on

body balance, muscle strength and power, stability and gait, and

bone mineral density. Although the authors combined the results

of different studies they did not carry out a formal meta-analysis

and did not disaggregate the results between unique and multiple-

session interventions. They concluded that WBV seems to have

positive effects on the analysed outcomes overall in special popu-

lations compared to resistance training and physiotherapy.

Our review has applied a sound methodology, reducing possible

sources of bias and we performed a comprehensive search. Also, to

our knowledge, this is the first systematic review of WBV in neu-

rodegenerative disease patients with a meta-analysis. Our results

corroborate those of the previous reviews.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

There is insufficient evidence to support the use of whole-body

vibration (WBV) intervention in neurodegenerative disease pa-

tients. This review is based on a limited number of studies with

several methodological shortcomings.

Implications for research

This review makes clear that further, longer studies are needed to

assess the efficacy of WBV in neurodegenerative diseases, over-

coming the limitations in the research so far, namely heterogeneity

in trial designs, outcome measures and interventions. Also, future

studies should be adequately powered and apply higher method-

ological standards (good generation random sequence, adequate

allocation concealment and blinding of outcome assessment). Ad-

ditionally, it is recommended that future studies are reported fol-

lowing the CONSORT extension for Non-pharmacological Treat-

ment interventions (Boutron 2008).

It would be appropriate to consider the evaluation of patients’ au-

tonomy in future research. Most studies have explored walking

and balance capacities with specific outcome measures. It is nec-

essary to investigate further the effects of WBV on more global

measures, such as functional health according to activities of daily

living (ADL) (e.g. Barthel Scale, Functional Independence Mea-

sure, etc.), reduction of signs and symptoms such as fatigue and

immobility, and quality of life.

Exercises to be performed should be thoroughly detailed in train-

ing protocols (e.g. high, deep, wide, wide stance squat and lunge)

and should be performed with closed eyes, or introducing external

objects that affect balance (e.g. fit balls, balloons, etc.), or intro-

ducing exercises adapting usual movements of daily life (Vreede

2004).

Muscle weakness is one of the contributing factors to postural

instability and ability to perform ADL in Parkinson’s disease (

Corcos 1996). Taking this into account, it would be interesting to

assess this parameter in future investigations in both Parkinson’s

disease and multiple sclerosis disorders.

Following the recommendations of the current evidence, it is im-

portant to evaluate the training protocol every four weeks in order

to adjust the rehabilitation programme according to the evolution

of the disease (Keus 2007). Another important point related to

continuous assessment is the need for a fatigue follow-up control,

before and after treatment. This last recommendation can be car-

ried out by applying the Borg Test and a visual analogue scale

(VAS) in each training session (Broekmans 2010). Finally, our re-

view has not focused on residual effects of WBV training. Keeping

in mind the prognosis of neurodegenerative diseases, it would be

important to specify the duration of effects.





A C K N O W L E D G E M E N T S

This review is part of the thesis of its first author, Mercè Sitjà-

Rabert, PhD candidate at the Universitat Autònoma de Barcelona,

Spain.

We would like to acknowledge the contribution of the Iberoamer-

ican Cochrane Centre for its guidance in developing the review,

Ivan Solà for his support in the searching and obtaining the arti-

cles, and Sera Tort for her assistance and help in the editing process

of the review. We also thank the Blanquerna Faculty of Health

Science (Universitat Ramon Llull) for their support to the first

author, providing her special leave to work on her thesis.

R E F E R E N C E S

References to studies included in this review

Arias 2009 {published data only}

Arias P, Chouza M, Vivas J, Cudeiro J. Effect of whole

body vibration in Parkinson’s disease: a controlled study.

Movement Disorders 2009;24(6):891–8.

Broekmans 2010 {published data only}

Broekmans T, Roelants M, Alders G, Feys P, ThijsH,

Eijnde BO. Exploring the effects of a 20-week whole-body

vibration training programme on leg muscle performance

and functional persons with multiple sclerosis. Journal of

Rehabilitation Medicine 2010;42:866–72.

Chouza 2011 {published data only}

Chouza M, Arias P, Viñas S, Cudeiro J. Acute effects of

whole-body vibration at 5, 6, and 9 Hz on balance and gait

in patients with Parkinson’s disease. Movement Disorders

2011;26(5):920–1.

Ebersbach 2008 {published data only}

Ebersbach G, Edler D, Kaufhold O, Wissel J. Whole body

vibration versus conventional physiotherapy to improve

balance and gait in Parkinson’s disease. Archives of Physical

Medicine and Rehabilitation 2008;89(3):399–403.

Haas 2006 (a) {published data only}

Haas CT, Buhlmann A, Turbanski S, Schmidtbleicher D.

Proprioceptive and sensorimotor performance in Parkinson’s

disease. Research in Sports Medicine 2006;14(4):273–87.

Haas 2006 (b) {published data only}

Haas CT, Turbanski S, Kessler K, Schmidtbleicher D.

The effects of random whole-body-vibration on motor

symptoms in Parkinson’s disease. NeuroRehabilitation 2006;

21(1):29–36.

Jackson 2008 {published data only}

Jackson KJ, Merriman HL, Vanderburgh PM, Brahler CJ.

Acute effects of whole-body vibration on lower extremity

muscle performance in persons with multiple sclerosis.

Journal of Neurologic Physical Therapy 2008;32(4):171–6.

Schuhfried 2005 {published data only}

Schuhfried O, Mittermaier C, Jovanovic T, Pieber K,

Paternostro-Sluga T. Effects of whole-body vibration in

patients with multiple sclerosis: a pilot study. Clinical

Rehabilitation 2005;19(5):834–42.

Schyns 2009 {published data only}

Schyns F, Paul L, Finlay K, Ferguson C, Noble E. Vibration

therapy in multiple sclerosis: a pilot study exploring its

effects on tone, muscle force, sensation and functional

performance. Clinical Rehabilitation 2009;23:771–81.

Turbanski 2005 {published data only}

Turbanski S, Haas CT, Schmidtbleicher D, Friedrich A,

Duisberg P. Effects of random whole-body vibration on

postural control in Parkinson’s disease. Research in Sports

Medicine 2005;13(3):243–56.

References to studies excluded from this review

Bautmans 2005 {published data only}

Bautmans I, Van Hees E, Lemper J, Mets T. The feasibility

of whole body vibration in institutionalised elderly persons

and its influence on muscle performance, balance and

mobility: a randomised controlled trial. BMC Geriatrics

2005;5:17–24.

Bedient 2009 {published data only}

Bedient AM, Adams JB, Edwards DA, Serravite DH,

Huntsman E, Mow SE, et al.Displacement and frequency

for maximizing power output resulting from a bout of

whole-body vibration. Journal of Strength and Conditioning

Research 2009;23(6):1683–7.

Bogaerts 2007 (a) {published data only}

Bogaerts A, Verschueren S, Delecluse C, Claessens AL,

Boonen S. Effects of whole body vibration training on

postural control in older individuals: a 1 year randomized

controlled trial. Gait Posture 2007;26(2):309–16.

Bogaerts 2007 (b) {published data only}

Bogaerts A, Delecluse C, Claessens AL, Coudyzer W,

Boonen S, Verschueren SM. Impact of whole-body vibration

training versus fitness training on muscle strength and

muscle mass in older men: a 1-year randomized controlled

trial. Journal of Gerontology: Biological Sciences 2007;62:

630–5.



Bogaerts 2009 {published data only}

Bogaerts AC, Delecluse C, Claessens AL, Troosters T,

Boonen S, Verschueren SM. Effects of whole body vibration

training on cardiorespiratory fitness and muscle strength in

older individuals (a 1-year randomised controlled trial). Age

and Ageing 2009;38(4):448–54.

Bogaerts 2011 {published data only}

Bogaerts A, Delecluse C, Boonen S, Claessens AL, Milisen

K, Verschueren SM. Changes in balance, functional

performance and fall risk following whole body vibration

training and vitamin D supplementation in institutionalized

elderly women. A 6 month randomized controlled trial.

Gait Posture 2011;33(3):466–72.

Brooke-Wavell 2009 {published data only}

Brooke-Wavell K, Mansfield NJ. Risks and benefits of whole

body vibration training in older people. Age and Ageing

2009;38(3):254–5.

Bruyere 2005 {published data only}

Bruyere O, Wuidart MA, Di Palma E, Gourlay M, Ethgen

O, Richy F, et al.Controlled whole body vibration to

decrease fall risk and improve health-related quality of life

of nursing home residents. Archives of Physical Medicine and

Rehabilitation 2005;86(2):303–7.

Cheung 2007 {published data only}

Cheung WH, Mok HW, Qin L, Sze PC, Lee KM, Leung

KS. High-frequency whole-body vibration improves

balancing ability in elderly women. Archives of Physical

Medicine and Rehabilitation 2007;88:852–7.

Corrie 2007 {published data only}

Corrie H, Brooke-Wavell K, Mansfield N, D’Souza O,

Griffiths V, Morris R, et al.A randomised controlled trial

on the effects of whole body vibration on muscle power in

older people at risk of falling. Osteoporosis International

2007;18(Suppl 3):253–4.

Cronin 2004 {published data only}

Cronin JB, Oliver M, McNair PJ. Muscle stiffness and

injury effects of whole body vibration. Physical Therapy in

Sport 2004;5(2):68–74.

Edwards 2009 {published data only}

Edwards LC. Neurophysiological responses to whole body

vibration. Dissertation Abstracts International Section A:

Humanities and Social Sciences 2009; Vol. 69, issue 12–A:

4669.

Feland 2008 {published data only}

Feland J, Hopkins T, Hunter I, Johnson W. Hamstring

stretching using a whole-body vibration platform. British

Journal of Sports Medicine 2008;42(6):519.

Feys 2006 {published data only}

Feys P, Helsen WF, Verschueren S, Swinnen SP, Klok I,

Lavrysen A, et al.Online movement control in multiple

sclerosis patients with tremor: effects of tendon vibration.

Movement Disorders 2006;21(8):1148-53.

Furness 2009 {published data only}

Furness TP, Maschette WE. Influence of whole body

vibration platform frequency on neuromuscular

performance of community-dwelling older adults. Journal

of Strength and Conditioning Research 2009;23(5):1508–13.

Furness 2010 {published data only}

Furness TP, Maschette WE, Lorenzen C, Naughton

GA, Williams MD. Efficacy of a whole-body vibration

intervention on functional performance of community-

dwelling older adults. Journal of Alternative and

Complementary Medicine 2010;16(7):795–7.

Ghoseiri 2009 {published data only}

Ghoseiri K, Forogh B, Sanjari M, Bavi A. Effects of

vibratory orthosis on balance in idiopathic Parkinson’s

disease. Disability & Rehabilitation: Assistive Technology

2009;4(1):58–63.

Gusi 2006 {published data only}

Gusi N, Raimundo A, Leal A. Low-frequency vibratory

exercise reduces the risk of bone fracture more than walking:

a randomized controlled trial. BMC Musculoskeletal

Disorders 2006;7:92–9.

Holland 1965 {published data only}

Holland CL Jr. Human response to random vibration.

Dissertation Abstracts 1965; Vol. 26, issue 2:1183–4.

Hornick 1962 {published data only}

Hornick RJ. Effects of whole-body vibration in three

directions upon human performance. Journal of Engineering

Psychology 1962;1(3):93–101.

Iwamoto 2005 {published data only}

Iwamoto J, Takeda T, Sato Y, Uzawa M. Effect of whole-

body vibration exercise on lumbar bone mineral density,

bone turnover, and chronic back pain in post-menopausal

osteoporotic women treated with alendronate. Aging

Clinical and Experimental Research 2005;17:157–63.

Jin 2007 {published data only}

Jin FY, Ruan XY. Mechanical vibration in the treatment of

postmenopausal women with knee osteoarthritis. Journal of

Clinical Rehabilitative Tissue Engineering Research 2007;11

(40):8099–102.

Johnson 2007 {published data only}

Johnson A. Whole-body vibration compared to traditional

physical therapy in individuals with total knee arthroplasty.

Faculty of Brigham Young University 2007.

Kawanabe 2007 {published data only}

Kawanabe K, Kawashima A, Sashimoto I, Takeda T, Sato

Y, Iwamoto J. Effect of whole-body vibration exercise and

muscle strengthening, balance, and walking exercises on

walking ability in the elderly. Keio Journal of Medicine 2007;

56(1):28–33.

King 2009 {published data only}

King LK, Almeida QJ, Ahonen H. Short-term effects of

vibration therapy on motor impairments in Parkinson’s

disease. NeuroRehabilitation 2009;25(4):297–306.

Machado 2010 {published data only}

Machado A, Garcia-Lopez D, Gonzalez-Gallego J,

Garatachea N. Whole-body vibration training increases

muscle strength and mass in older women: a randomized-



controlled trial. Scandinavian Journal of Medicine and

Science in Sports 2010;20(2):200–7.

Raimundo 2009 {published data only}

Raimundo AM, Gusi N, Tomas-Carus P. Fitness efficacy of

vibratory exercise compared to walking in postmenopausal

women. European Journal of Applied Physiology 2009;106

(5):741–8.

Rees 2007 {published data only}

Rees SS, Murphy AJ, Watsford ML. Effects of vibration

exercise on muscle performance and mobility in an older

population. Journal of Aging and Physical Activity 2007;15:

367–81.


Rees SS, Murphy AJ, Watsford ML. Effects of whole-body

vibration exercise on lower-extremity muscle strength and

power in an older population: a randomized clinical trial.

Physical Therapy 2008;88:462–70.


Rees SS, Murphy AJ, Watsford ML. Effects of whole body

vibration on postural steadiness in an older population.

Journal of Science and Medicine in Sport 2009;12(4):440–4.

Roelants 2004 {published data only}

Roelants M, Delecluse C, Verschueren SM. Whole-body-

vibration training increases knee-extension strength and

speed of movement in older women. Journal of the American

Geriatrics Society 2004;52(6):901–8.

Rubin 2004 {published data only}

Rubin C, Recker R, Cullen D, Ryaby J, McCabe J, McLeod

K. Prevention of postmenopausal bone loss by a low-

magnitude, high-frequency mechanical stimuli: a clinical

trial assessing compliance, efficacy, and safety. Journal of

Bone and Mineral Research 2004;19:343–51.

Russo 2003 {published data only}

Russo CR, Lauretani F, Bandinelli S, Bartali B, Cavazzini

C, Guralnik JM, et al.High-frequency vibration training

increases muscle power in postmenopausal women. Archives

of Physical Medicine and Rehabilitation 2003;84:1854–7.

Savelberg 2007 {published data only}

Savelberg HH, Keizer HA, Meijer K. Whole-body vibration

induced adaptation in knee extensors; consequences of

initial strength, vibration frequency, and joint angle. Journal

of Strength and Conditioning Research 2007;21(2):589–93.

Trans 2009 {published data only}

Trans T, Aaboe J, Henriksen M, Christensen R, Bliddal

H, Lund H. Effect of whole body vibration exercise on

muscle strength and proprioception in females with knee

osteoarthritis. Knee 2009;16(4):256–61.

Verschueren 2004 {published data only}

Verschueren SM, Roelants M, Delecluse C, Swinnen S,

Vanderschueren D, Boonen S. Effect of 6-month whole

body vibration training on hip density, muscle strength, and

postural control in postmenopausal women: a randomized

controlled pilot study. Journal of Bone and Mineral Research

2004;19:352–9.

Verschueren 2011 {published data only}

Verschueren SM, Bogaerts A, Delecluse C, Claessens AL,

Haentjens P, Vanderschueren D, et al.The effects of whole-

body vibration training and vitamin D supplementation

on muscle strength, muscle mass, and bone density in

institutionalized elderly women: a 6-month randomized,

controlled trial. Journal of Bone and Mineral Research 2011;

26(1):42–9.

Wigg 1999 {published data only}

Wigg A. The effect of whole body vibration on height.

Journal of Bone and Joint Surgery-British 1999;81(Suppl 1):

19.

Wunderer 2010 {published data only}

Wunderer K, Schabrun SM, Chipchase LS. Effects of whole

body vibration on strength and functional mobility in

multiple sclerosis. Physiotherapy Theory and Practice 2010;

26(6):374–84.

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C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Arias 2009

Methods Quasi-random clinical trial

Parallel, unicentric

Losses: 2 of 23 (8.7%)

Participants Setting: community, Spain

Randomised = 23; assessed = 21

Demographic characteristics given over 21 participants

Age: intervention group: mean 66.5 (SD 5.57) years; comparison group: mean 66.9 (SD

11.11) years

Sex: intervention group: female 40%; comparison group: female 45.4%

Inclusion criteria: Parkinson’s disease (based on medical records); lack of dementia

(MMSE ≥ 24); lack of artromuscular deficit or joint prosthesis; be able to cope with

OFF periods

Interventions 1. 12 WBV sessions over 5 weeks on non-consecutive days. Each session included 5 sets

of vibration (6 Hz) 1 minute each and 1-minute rest between sets

2. Comparison: same schedule but standing on platform and vibration was not applied

All participants were asked to stand on platform with the knees slightly bent

Outcomes Body Balance (Berg balance test (score), Functional Reach (mm))

Gait (velocity (m/s), cadence (steps/s), step amplitude(m), turn time(s), TUG test (s))

Signs and symptoms of the disease (UPDRS, total and motor score)

Quality of life (PDQ-39 (score))

Others: pegboard test (number of pegs)

Notes All other physical therapies usually undergone by the patients were cancelled during the

duration of the study. Patients did not change their medication and intervention started

30 to 45 min after dose intake (when patients confirmed ON periods)

For intra-session evaluation patients (short-term effects) were evaluated during the ON

periods. For the effect of the programme (long-term effects) patients were evaluated

during their OFF periods, except in the Parkinson’s disease questionnaire (PDQ-39)

which was evaluated during ON periods

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

High risk Patients were allocated to either experimen-

tal or placebo group based upon an ABBA

(A: experimental; B: placebo) distribution

model

Allocation concealment (selection bias) High risk ABBA distribution model



Arias 2009 (Continued)

Blinding (performance bias and detection

bias)

All outcomes

Unclear risk It is not clear if patients were blinded to

the intervention because they adopted the

same position but vibration was not applied

Selective reporting (reporting bias) Low risk All analysed outcomes included in the pub-

lished report

Other bias Low risk No other risks of bias detected

Blinded assessor Low risk All evaluations were performed by re-

searchers blind to protocol and group as-

signment

Broekmans 2010

Methods RCT

Parallel

Losses: 2 of 25 (8%)

Participants Setting: community, Belgium



Age: intervention group: mean 46.1 (SE 2.1) years; comparison group: mean 49.7 (SE

3.3) years

Sex: intervention group: female 63.6%; comparison group: female 78.6%

Inclusion criteria: community-based patients with multiple sclerosis residing in Hasselt

region (Belgium)

Exclusion criteria: > 3 relapses in the preceding 1 year or > 1.0 Expanded Disability Status

Scale (EDSS) increase in the preceding year; corticosteroid treatment 28 days before the

study start; pregnancy; severe psychiatric disorders; internal materials for bone fixation

and/or total joint replacements; any contra-indication for light to moderately intense

physical exercise

Interventions 1. 5 WBV sessions every 2 weeks over 20 weeks. Each session included a progressive

series of exercises with a rest period ranging from 2 min to 30 sec between exercises.

Vibration was delivered at a range of 20 to 45 Hz and amplitude of 2.5 mm

2. Comparison: usual lifestyle

Outcomes Body Balance (Berg balance test (score))

Gait (TUG test (s), 2-minute walk test (m), the 25-foot walk test (s))

Muscle performance (maximal isometric torque (Nm), maximal dynamic torque (Nm)

, maximal strength endurance (J), maximal speed of movement of knee extension (º/s),

all through isokinetic dynamometer - Biodex Medical Systems®)

Notes Each WBV exercise session lasted for a maximum of 50 min including warming up and

cooling down that involved stretching of the major lower limb muscle groups

All muscle performance tests assessed maximal voluntary unilateral knee strength of the

right leg. Data were available for isometric torque of knee extensors and flexors at 45º and



Broekmans 2010 (Continued)

90º, for dynamic torque of knee extensor at a velocity of 60º/sec, for strength endurance

at a velocity of 180º/sec

Risk of bias



bias)

Unclear risk No information provided

Allocation concealment (selection bias) Unclear risk No information provided


bias)

All outcomes

High risk Not blinded

Selective reporting (reporting bias) Low risk All analysed outcomes included in the published

report


Blinded assessor High risk Only the neurologist who determined the Ex-

panded Disability Status Scale (EDSS) score was

blinded

Chouza 2011

Methods RCT

Parallel

Losses: none

Participants Setting: unknown, Spain



Age: intervention group 1: mean 68.92 (SD 7.86) years; sex: intervention group 1: female

66.6%


50%


58.3%


50%

Inclusion criteria: idiopathic Parkinson’s disease

Exclusion criteria: had any other disease or impairment potentially affected the validity

of the results

Interventions Group 1: a single WBV session delivered at 3 Hz (amplitude of 13 mm), during 5 sets

of 1 min each (interset rest period of 1 min)

Group 2: a single WBV session delivered at 6 Hz (amplitude of 13 mm), during 5 sets



Chouza 2011 (Continued)


Group 3: a single WBV session delivered at 9 Hz (amplitude of 13 mm), during 5 sets


Group 4: patients performed the same exercises without vibration (with the knees slightly

flexed)

Outcomes Body balance (Functional Reach test (mm))

Gait (TUG test (s))

Notes All patients were tested in the ON phase

This study was published as a letter to the editor

Risk of bias



bias)




bias)

All outcomes


Selective reporting (reporting bias) Low risk All analysed outcomes included in the published report


Blinded assessor Low risk Examiners were blind to protocol and group assignment

Ebersbach 2008



Losses: 6 of 27 (22.2%)

Participants Setting: hospital, Germany


Demographic characteristics given over 21 participants.


6.8) years

Sex: intervention group: female 30%; comparison group: female 36.4%

Inclusion criteria: idiopathic Parkinson’s disease (diagnosed according to standard clinical

criteria); clinical evidence for imbalance, scoring at least 1 point on item 30 of the Unified

Parkinson’s Disease Rating Scale (UPDRS) while being on optimised and stable

medical treatment

Exclusion criteria: severe response fluctuations or other conditions requiring modification



Ebersbach 2008 (Continued)

of medication, dementia, balance impairment due to other disease and severe dyskinesia

interfering with posturographic assessments

Interventions 1. WBV sessions over 3 weeks (a total of 30): 5 days a week, twice a day. Each session

included 15 minutes of vibration, delivered to frequency of 25 Hz and to an amplitude

ranging from 7 to 14 mm

Patients stand with slightly bended knees and hips while WBV is delivered and are

instructed not to hold onto the railing during WBV

2. Comparison: standard balance training including exercises on a tilt board

Outcomes Body Balance (Tinetti balance scale (score), Pull test score, Posturography (mm))

Gait (time to walk 10 m (s), stand-walk-sit (s))

Signs and symptoms of the diseases (UPDRS motor score)

Notes All patients received standard therapy comprising 3 sessions a day (5 days a week, 40

minutes a session) including relaxation techniques (group exercises focusing on muscle-

stretching, relaxation and body perception), speech therapy and occupational therapy

All patients were tested in the ON phase

Risk of bias



bias)

High risk Alternating allocation

Allocation concealment (selection bias) High risk Alternating allocation


bias)

All outcomes



lished report


Blinded assessor Low risk Only Tinetti balance scale and UPDRS

tests were measured by a neurologist who

was blinded to the group allocation



Haas 2006 (a)



Losses: 2 of 28 (7.1%)

Participants Setting: unknown, Germany



Age: in both groups averaged 63.1 years

Sex: unknown


Exclusion criteria: dementia; cerebellar signs; abnormal brain imaging; or fundamental

co-morbidities like neuropathy, muscle or joint diseases, dyskinesias, sustainable leg or

postural tremor, and strong asymmetrical symptom structure

Interventions Group 1: a single WBV session delivered at 6 Hz (5 vibration series of 1 minute each

and 1-minute break between them)

Group 2: resting period of 15 min

Outcomes Body balance: proprioception (º)

Signs and symptoms of the disease: bradykinesia (movement velocity to knee flexion and

vice versa (timing))


Risk of bias



bias)

High risk Patients were quasi-randomly subdivided

into groups



bias)

All outcomes


Selective reporting (reporting bias) High risk Do not report results of movement velocity

Other bias High risk Unbalanced groups (19 patients in inter-

vention group and 9 patients in control

group)

Blinded assessor High risk Not blinded



Haas 2006 (b)

Methods RCT

Cross-over

Losses: none

Participants Setting: community, Germany



Age: mean 65.0 (SD 7.8) years

Sex: female 22%

Inclusion criteria: diagnosis of Parkinson’s disease on the basis of unilateral onset, asym-

metric motor symptoms, symptom relief by dopaminergic treatment, and absence of

atypical clinical signs such as severe orthostatic hypotension, cerebellar or pyramidal

signs, early falls or gaze abnormalities, and normal brain imaging

Exclusion criteria: patients with dementia or other diseases impairing gait, stance or co-

ordination (e.g. neuropathy, muscle or joint disease), unable to stand unsupported

Interventions Group 1: a single WBV session delivered at 6 Hz and at an amplitude of 3 mm (5

vibration series of 1 minute each and 1-minute break between them); then a resting

period

Group 2: received first the resting period and WBV session thereafter (same delivery

schedule)

Outcomes Signs and symptoms of the disease (UPDRS, motor score)

Notes To exclude the influence of medication all patients were withdrawn from L-DOPA over

night (> 12 hours). Patients were not withdrawn from dopamine agonists

All patients were tested in the ON phase

Risk of bias



bias)




bias)

All outcomes


Selective reporting (reporting bias) Low risk All analysed outcomes included in the published report

Other bias High risk There is no wash-out period between intervention

phases that may lead to a carry-over effect

Blinded assessor Low risk Scoring was carried out by an assessor blinded to the

treatment status of the patient



Jackson 2008

Methods RCT

Cross-over, unicentric

Losses: none

Participants Setting: community, US




Sex: female 80%

Inclusion criteria: a confirmed diagnosis of multiple sclerosis, ability to ambulate 10 m

with or without assistive device with no more than contact guard assistance, ability to

stand for a minimum of 5 minutes with upper extremity support

Exclusion criteria: thrombosis, acute inflammation, acute tendinopathy, recent (less than

6 months) fractures, gallstones, implants, surgery, wound/scar, hernia or discopathy,

diabetic retinopathy, epilepsy, pacemaker, pregnancy, total joint replacement, or the

presence of any other neurological condition

Interventions Group 1: a single WBV session delivered at 2 Hz first and then at 26 Hz (amplitude of

6 mm), during 30 sec each

Group 2: received the alternate vibratory frequency

All participants were asked to stand on platform with the knees slightly bent

There was a 1-week period between sessions

Outcomes Muscle performance (maximal isometric torque of knee extensors and flexors (Nm)) all

through isokinetic dynamometer - Biodex Medical Systems®

Notes All assessments were performed at 1, 10 and 20 minutes after intervention

Risk of bias



bias)




bias)

All outcomes



lished report


Blinded assessor Low risk The investigator responsible for performing

the muscle testing was blinded to the type

of intervention



Schuhfried 2005

Methods RCT


Losses: none

Participants Setting: community, Austria




12.7) years

Sex: intervention group: female 83.3%; comparison group: female 66.6%

Inclusion criteria: multiple sclerosis with a score ≤5 on Kurtzke’s Expanded Disability

Status Scale (EDSS), with balance disorders, gait insecurities and/or ataxia. The patients

needed to stand independently, without assistive devices or external support

Exclusion criteria: pregnancy, electronic implants such as pacemakers, artificial heart

valves, epilepsy, malignant tumours, endoprosthesis, recent fracture (less than 6 months)

, osteoporosis with vertebral body fracture, thrombosis, therapy with anticoagulant med-

ication, relapse of multiple sclerosis in the last 2 months and refusal to participate

Interventions Group 1: a single WBV session delivered at 2 to 4.4 Hz and at an amplitude of 3 mm

(5 vibration series of 1 minute each and 1-minute break between them)

Group 2: standing exercises (with slight flexion at the hips, knees and ankle joints) while

transcutaneous electrical nerve stimulation (TENS) in the forearm

Outcomes Body Balance (posturography through the Sensory Organization Test (points), Func-

tional Reach test (mm))

Gait (TUG test (s))

Notes All assessments were performed at 15 minutes, 1 and 2 weeks after intervention

Risk of bias



bias)




bias)

All outcomes

Low risk The interventions were performed by a profes-

sional not involved in the study. Patients not

blinded


lished report


Blinded assessor Low risk All outcome assessments were obtained in

blinded conditions



Schyns 2009


Cross-over study, unicentric

Losses: 4 of 16 (25%)

Participants Setting: community, Scotland (United Kingdom)

Randomised = 16; assessed = 12 or 10 (variable depending on the outcome)

Age: group 1: mean 45.8 (SD 8.4) years; group 2: mean 45.5 (SD 6.14) years

Sex: group 1: female 62.5%; group 2: female 87.5%

Inclusion criteria: confirmed diagnosis of multiple sclerosis (disability level between 1

and 6 on the Hauser Ambulation Index); at least 1 of the following symptoms: abnormal

muscle tone, lower limb weakness, altered sensation and/or proprioception

Exclusion criteria: were receiving ongoing physiotherapy or other types of exercise class;

were receiving complementary therapy (e.g. acupuncture, reflexology and aromatherapy)

; had previous or current use of whole-body vibration, or presented with any contraindi-

cations of whole-body vibration such as tumour, pacemaker, pregnancy, epilepsy, severe

pain, active infection or dizziness

Interventions Group 1: were randomised to receive 3 WBV sessions a week over 4 weeks and then to

perform the same exercises without vibration

Group 2: the order of interventions was reversed

Each WBV session included several sets of vibration (delivered at 30 to 50 Hz and at an

amplitude of 2 to 4 mm)

Before cross-over a 2-weeks rest period was considered

Outcomes Balance (proprioception by Nottingham Sensory Assessment (score))

Gait (TUG test (s), 10-metre walk test (s))

Signs and symptoms of the disease (Multiple Sclerosis Spasticity Scale MSSS-88 (score)

, Modified Ashworth Scale (score), subjective perception of symptoms)

Muscle performance (maximal isometric force (N), through hand-held dynamometer

using ’make test’)

Quality of life (multiple sclerosis Impact Scale-MSIS-29 (score)

Notes Detailed information about the intervention protocol is given in paper

Risk of bias



bias)

High risk Patients were randomised by drawing a

number from an envelope

Allocation concealment (selection bias) High risk High probability of not being concealed


bias)

All outcomes



lished report



Schyns 2009 (Continued)

Other bias Low risk Statistical analysis excluded a carry-over ef-

fect

Blinded assessor Low risk All measures were performed by a physio-

therapist who was not involved in the train-

ing procedure and who was blind to the

group allocation

Turbanski 2005

Methods Controlled trial (not clear if randomised)


Losses: none

Participants Setting: unknown, Germany



Sex: female 29.9%


Exclusion criteria: dementia, heart diseases, neurological diseases apart from Parkinson

disease, significant dyskinesias and orthopaedic injuries

Interventions Group 1: a single WBV session delivered at 6 Hz and at an amplitude of 3 mm (5ve

vibration series of 1 minute each and 1-minute break between them)

Group 2: moderate walk (15 min)

Outcomes Body balance (postural stability on a movable and instable platform, Coordex®, Ger-

many) on both narrow and tandem standing positions


Risk of bias



bias)

Unclear risk Participants were divided equally into ex-

perimental and control groups



bias)

All outcomes



lished report




Turbanski 2005 (Continued)

Blinded assessor Unclear risk No information provided

L-Dopa: Levadopa

MMSE: Mini-Mental State Examination

min: minute

PDQ: Parkinson’s disease questionnaire

RCT: randomised controlled trial

SD: standard deviation

SE: standard error

sec: second

TUG: Timed Up and Go test

UPDRS: Unified Parkinson’s Disease Rating Scale

WBV: whole-body vibration

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Bautmans 2005 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in older persons

Bedient 2009 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in moderately trained recreational athletes

Bogaerts 2007 (a) Types of participants did not include persons with any type of neurodegenerative illness; the study was


Bogaerts 2007 (b) Types of participants did not include persons with any type of neurodegenerative illness

Bogaerts 2009 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Bogaerts 2011 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Brooke-Wavell 2009 The study design was not a randomised controlled trial

Bruyere 2005 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Cheung 2007 Types of participants did not include persons with any type of neurodegenerative illness; the study was




(Continued)

Corrie 2007 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Cronin 2004 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in healthy young people

Edwards 2009 Types of participants did not include persons with any type of neurodegenerative illness

Feland 2008 Types of participants did not include persons with any type of neurodegenerative illness

Feys 2006 The study applied an intervention with tendon vibration, did not include an intervention of whole-body

vibration

Furness 2009 Types of participants did not include persons with any type of neurodegenerative illness

Furness 2010 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in older adults

Ghoseiri 2009 The study did not include an intervention of whole-body vibration. The intervention was performed by a

vibratory orthosis on lumbar spine

Gusi 2006 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in postmenopausal women

Holland 1965 The study did not include an intervention of whole-body vibration

Hornick 1962 The study did not include an intervention of whole-body vibration

Iwamoto 2005 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Jin 2007 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Johnson 2007 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in patients with total knee arthroplasty

Kawanabe 2007 Types of participants did not include persons with any type of neurodegenerative illness; the study was


King 2009 Vibrations were applied using a Physioacoustic method

Machado 2010 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Raimundo 2009 Types of participants did not include persons with any type of neurodegenerative illness; the study was




(Continued)

Rees 2007 Types of participants did not include persons with any type of neurodegenerative illness; the study was






Roelants 2004 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Rubin 2004 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Russo 2003 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Savelberg 2007 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in healthy young people

Trans 2009 Types of participants did not include persons with any type of neurodegenerative illness; the study was

performed in women diagnosed with osteoarthritis

Verschueren 2004 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Verschueren 2011 Types of participants did not include persons with any type of neurodegenerative illness; the study was


Wigg 1999 Types of participants did not include persons with any type of neurodegenerative illness

Wunderer 2010 The study design was not a randomised controlled trial; there was a single patient experimental design



D A T A A N D A N A L Y S E S

Comparison 1. Whole-body vibration vs an active physical therapy (short-term effects) in Parkinson’s disease

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Body balance (Functional Reach) 2 45 Mean Difference (IV, Fixed, 95% CI) 19.83 [-20.99, 60.

65]

2 Gait (Timed Up and Go test) 2 45 Mean Difference (IV, Fixed, 95% CI) -3.09 [-5.60, -0.59]

Comparison 2. Whole-body vibration vs an active physical therapy (long-term effects) in Parkinson’s disease

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 UPDRS III motor score 2 42 Mean Difference (IV, Fixed, 95% CI) -0.65 [-3.98, 2.68]

2 Body balance (Berg Balance

Scale and Tinetti test)

2 42 Std. Mean Difference (IV, Fixed, 95% CI) 0.36 [-0.26, 0.97]

3 Gait (TUG test and

Stand-walk-sit test)

2 42 Std. Mean Difference (IV, Fixed, 95% CI) -0.41 [-1.02, 0.21]

Analysis 1.1. Comparison 1 Whole-body vibration vs an active physical therapy (short-term effects) in

Parkinson’s disease, Outcome 1 Body balance (Functional Reach).

Review: Whole-body vibration training for patients with neurodegenerative disease

Comparison: 1 Whole-body vibration vs an active physical therapy (short-term effects) in Parkinson’s disease

Outcome: 1 Body balance (Functional Reach)

Study or subgroup

Wholebody

vibration

Activephysicaltherapy

MeanDifference Weight

MeanDifference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Arias 2009 11 260.75 (80.12) 10 244.6 (63.65) 43.9 % 16.15 [ -45.48, 77.78 ]

Chouza 2011 12 264.4 (74.1) 12 241.7 (61.5) 56.1 % 22.70 [ -31.78, 77.18 ]

Total (95% CI) 23 22 100.0 % 19.83 [ -20.99, 60.65 ]

Heterogeneity: Chi2 = 0.02, df = 1 (P = 0.88); I2 =0.0%

Test for overall effect: Z = 0.95 (P = 0.34)

Test for subgroup differences: Not applicable

-100 -50 0 50 100

Favours Active physical therapy Favours Whole body vibration



Analysis 1.2. Comparison 1 Whole-body vibration vs an active physical therapy (short-term effects) in

Parkinson’s disease, Outcome 2 Gait (Timed Up and Go test).


Comparison: 1 Whole-body vibration vs an active physical therapy (short-term effects) in Parkinson’s disease

Outcome: 2 Gait (Timed Up and Go test)

Study or subgroup

Wholebody

vibration



MeanDifference


Arias 2009 10 11.9 (2.22) 11 15 (5.7) 47.2 % -3.10 [ -6.74, 0.54 ]

Chouza 2011 12 12.23 (2.6) 12 15.32 (5.5) 52.8 % -3.09 [ -6.53, 0.35 ]

Total (95% CI) 22 23 100.0 % -3.09 [ -5.60, -0.59 ]




-10 -5 0 5 10

Favours Whole body vibration Favours Active physical therapy



Analysis 2.1. Comparison 2 Whole-body vibration vs an active physical therapy (long-term effects) in

Parkinson’s disease, Outcome 1 UPDRS III motor score.


Comparison: 2 Whole-body vibration vs an active physical therapy (long-term effects) in Parkinson’s disease

Outcome: 1 UPDRS III motor score

Study or subgroup

Wholebody

vibration



MeanDifference


Arias 2009 10 21.2 (7.4) 11 24.6 (6) 32.9 % -3.40 [ -9.20, 2.40 ]

Ebersbach 2008 10 17.6 (4.5) 11 16.9 (5) 67.1 % 0.70 [ -3.36, 4.76 ]

Total (95% CI) 20 22 100.0 % -0.65 [ -3.98, 2.68 ]

Heterogeneity: Chi2 = 1.29, df = 1 (P = 0.26); I2 =22%



-10 -5 0 5 10



Parkinson’s disease, Outcome 2 Body balance (Berg Balance Scale and Tinetti test).



Outcome: 2 Body balance (Berg Balance Scale and Tinetti test)

Study or subgroup

Wholebody

vibrartion


Std.Mean

Difference Weight

Std.Mean

Difference


Arias 2009 10 49 (6.04) 11 47.8 (8.8) 51.1 % 0.15 [ -0.71, 1.01 ]

Ebersbach 2008 10 12.8 (1.9) 11 11.5 (2.4) 48.9 % 0.57 [ -0.30, 1.45 ]

Total (95% CI) 20 22 100.0 % 0.36 [ -0.26, 0.97 ]




-4 -2 0 2 4

Favours Active physical therapy Favours Whole body vibrartion




Parkinson’s disease, Outcome 3 Gait (TUG test and Stand-walk-sit test).



Outcome: 3 Gait (TUG test and Stand-walk-sit test)

Study or subgroup

Wholebody

vibrartion


Std.Mean

Difference Weight

Std.Mean

Difference


Arias 2009 10 11.7 (3.3) 11 13.3 (5) 50.3 % -0.36 [ -1.22, 0.51 ]

Ebersbach 2008 10 8.5 (2.1) 11 9.5 (2.1) 49.7 % -0.46 [ -1.33, 0.41 ]

Total (95% CI) 20 22 100.0 % -0.41 [ -1.02, 0.21 ]




-4 -2 0 2 4


A P P E N D I C E S

Appendix 1. EMBASE (Ovid) search strategy

1 exp Whole Body Vibration/ OR whole body vibration.mp. OR wbv.mp.

2 random:.tw. or clinical trial:.mp. or exp treatment outcome/

3 1 AND 2

Appendix 2. PeDro (website) search strategy

1 Abstract & Title: whole body vibration

2 Abstract & Title: wbv

3 1 or 2



Appendix 3. CENTRAL (CLib) Search strategy

1 (whole next body next vibration)

2 wbv

3 1 or 2

Appendix 4. CINAHL (EBSCOhost) search strategy

1 (MH “Vibration/AE/TU”)

2 whole body vibration

3 wbv

4 1 or 2 or 3

5 random* OR trial OR blind*

6 compare* OR comparison*

7 alocat*

8 group*

9 5 or 6 or 7 or 8

10 4 and 9

Appendix 5. PsycINFO (Ovid) search strategy

1 whole body vibration.mp.

2 wbv.mp.

3 1 or 2

4 (control: or random:).tw. or exp treatment/

5 4 and 3

H I S T O R Y

Protocol first published: Issue 6, 2011

Review first published: Issue 2, 2012

C O N T R I B U T I O N S O F A U T H O R S

Mercè Sitjà-Rabert (MSR) conceived, designed and co-ordinated the review. She screened titles and abstracts of references identified by

the search, selected and assessed trials, extracted trial and outcome data, carried out quality assessment and data extraction, contacted

trial lists about unpublished data, entered data into RevMan, wrote the review, provided a clinical perspective and contributed to and

approved the final manuscript of the review.

David Rigau (DR) conceived and designed the review. He screened titles and abstracts of references identified by the search, located,

selected and assessed trials, extracted trial and outcome data, assessed the methodological quality of selected trials, contacted trial lists

about unpublished data, entered data into RevMan, provided a methodological perspective and contributed to and approved the final

manuscript of the review.

Azahara Fort-Vanmeerhaeghe (AFV) screened titles and abstracts of references identified by the search, located, selected and assessed

trials, extracted trial and outcome data, assessed the methodological quality of selected trials. She provided a physical training perspective,

commented on drafts of the review and contributed to and approved the final manuscript of the review.

Carme Santoyo Medina (CSM) commented on drafts of the review, provided a clinical perspective and contributed to and approved

the final manuscript of the review.

Marta Roqué i Fíguls (MRF) extracted trial and outcome data, carried out statistical analysis, helped with the interpretation of the

data, drafted the review and approved the final manuscript of the review.



Dani Romero-Rodríguez (DRR) commented on drafts of the review, provided a physical training perspective, and contributed to and

approved the final manuscript of the review.

Xavier Bonfill Cosp (XBC) provided a methodological and clinical perspective, commented on drafts of the review, and contributed to

and approved the final manuscript of the review.

D E C L A R A T I O N S O F I N T E R E S T

None known.

S O U R C E S O F S U P P O R T

Internal sources

• None, Not specified.

External sources

• None, Not specified.

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

There are some differences between the protocol and the review briefly described below. We have extended the background with the

aim of providinga broader context for the topic of interest.

We decided to change the outcome ’Functional capacity according to basic activities of daily living (ADL)’ to ’Functional performance

according to basic activities of daily living (ADL)’. Additionally, we included muscular strength and muscular power in the outcome

’Muscle performance’, as this term is more global.

In the methods section, we simplified the comparisons as we compared WBV to control and WBV to active physical therapies. We also

included comparisons of different WBV modalities because we have extended the objective of the review. We incorporated an analysis

for subgroups as we decided to include the studies that analysed the short-term effects of WBV. We considered that combining the

results with single and multiple sessions could lead to non comparable results.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Activities of Daily Living; Exercise Therapy [methods]; Gait; Multiple Sclerosis [∗rehabilitation]; Muscle Strength; Neurodegenerative

Diseases [rehabilitation]; Parkinson Disease [∗rehabilitation]; Postural Balance; Randomized Controlled Trials as Topic; Vibration

[∗therapeutic use]



MeSH check words

Aged; Female; Humans; Male; Middle Aged



cochrane database of systematic reviews (reviews) || whole-body vibration training for patients with...

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